Acromioclavicular joint (AC) injuries are associated with damage to the joint and surrounding structures.
ANATOMY
The acromioclavicular joint, together with the sternoclavicular joint, connects the upper limb to the skeleton.
The support of the acromioclavicular joint is provided by the ligament and muscle surrounding the joint. The capsule surrounding the acromioclavicular joint is strengthened by the acromioclavicular ligaments. The joints are acromioclavicular ligaments that provide horizontal stability.
The coracoclavicular ligaments consist of two parts, the lateral trapezoid, and the medial conoid, and connect the distal lower clavicle to the coracoid process of the scapula. The coracoclavicular ligament is the main stabilizing ligament of the upper limb.
EPIDEMIOLOGY
Acromioclavicular joint injuries occur at all ages, but are most common in the 20-40 year age group, 5x times more common in men than women. It is a common contact sports injury in young male athletes (1).
PATHOLOGY
There are two main mechanisms of acromioclavicular joint injury; direct and indirect (2). A direct blow or fall to the shoulder results in a superior force on the acromion with restricted clavicular movement in the joint, the acromion is forcibly pushed down and medially relative to the clavicle. It can occur indirectly as a result of a fall on the hand or elbow, causing the humerus to be pushed into the acromion, resulting in lower-grade injuries that typically protect the coracoclavicular ligament.
CLASSIFICATION
Imaging can be used to classify acromioclavicular injuries and is the most widely used Rockwood classification.
ROCKWOOD CLASSIFICATION
References and Further Reading
Dyan V. Flores, Paola Kuenzer Goes, Catalina Mejía Gómez et-al. Imaging of the Acromioclavicular Joint: Anatomy, Function, Pathologic Features, and Treatment. (2020) RadioGraphics. 40 (5): 1355-1382.
Vanhoenacker F, Maas M, Gielen JL. Imaging of Orthopedic Sports Injuries. (2006)
Tintinalli’s Emergency Medicine, A Comprehensive Study Guide 9th edition. ( 2019)
Sepsis is a composite of symptoms and clinical signs that correspond to infection within a patient. This clinically heterogeneous syndrome may be fatal due to the extensive inflammatory processes and organ dysfunction it can provoke.
The New Definition of Sepsis
In 2016, after a revision by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, sepsis was redefined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection.”
This new definition of sepsis means that the patient’s body, in response to infection, reacts by causing damage to its own organ structures, and this process can progress to the point where death can be an unfortunate end result.
Along with this up-to-date definition of sepsis, up-to-date criteria for evaluating sepsis were also provided; however, let’s first consider the causes of sepsis.
What is the Aetiology of Sepsis?
Sepsis can be caused by various organisms ranging from viruses to fungi to protozoans; however, bacterial infections are the main offenders. Vincent et al. (2009) concluded in the international EPIC II study that gram-negative bacteria were the principal perpetrators, accounting for 62%, while the gram-positives followed with a frequency of 47%. Of these groups, the principle organisms include:
Staphylococcus aureus and Pseudomonas at 20%
Escherichia coli at 16%
Different risk factors may predispose persons to become infected by these organisms.
The presentation of sepsis ranges from acute to insidious. There are cases where the patient may indicate a site of infection to cases where there is none apparent. Symptoms and signs of this syndrome generally include the following:
Another early sign of sepsis includes the presence of leukopenia or leukocytosis. Along with these parameters, there are also specific signs within each organ system that must also be taken into account when investigating the source of primary infection or exploring the secondary effects of the same.
For example, when examining the respiratory system, listen for adventitious sounds or decreased breath sounds that may point to pneumonia and other chest infections. Respiratory causes of sepsis account for 42% of cases, according to the EPIC II study.
Patients who present with abdominal pain should be evaluated to rule out infection sources in abdominal structures such as the appendix, colon, pancreas, gallbladder. Other sources of infection may include the urinary tract and the prostate gland.
Patients with a history of trauma, wounds, and recent surgeries should be evaluated for any signs of wound infection (e.g., pain, erythema, purulent discharge, weeping wound, abscess formation)
In patients who are already admitted to the hospital and have been given invasive adjuncts, such as a central line, urinary catheters, and hemodialysis access sites, evaluate for inflammatory signs around the insertion site.
Warning Signs of Severe Sepsis
Sepsis progresses through a continuum that begins with a systemic inflammatory response syndrome (SIRS) and ends with multi-organ dysfunction syndrome (MODS), where mortality is almost inevitable. Its severest form is known as Septic Shock, a subcategory of sepsis where there is a great probability of mortality due to severe metabolic and circulatory irregularities.
The New Criteria for Evaluating Sepsis
The Sequential Organ Failure Assessment score, otherwise known as the SOFA score, is the new criteria used to evaluate sepsis. It replaces the SIRS Criteria.
SOFA takes into consideration six parameters that relate to specific organ systems. These systems are aligned with clinical signs and laboratory values, which fit into a numerical score ranging from 0 to 4, where 0 corresponds to normal values, and 4 corresponds to a high level of organ failure. See the image below, adapted from Vincent et al. (1996).
Since this criteria at its base enable physicians to assess the level of dysfunction occurring in the patient’s organ systems, the higher the score given, the more probable there will be an increase in mortality.
Using the SOFA criteria, a score equal to and greater than 2 in the presence of confirmed or suspected infection corresponds to organ dysfunction. It indicates a mortality risk of around 10%.
The abbreviated version of the SOFA score, known as quick SOFA or qSOFA, is helpful for screening patients suspected to have sepsis by quickly evaluating three parameters, mental status, systolic blood pressure, and the respiratory rate.
REBELEM Blog (2016) qSOFA Score
Laboratory and Imaging
The general laboratory, imaging, and special studies for sepsis can include various tests depending on the suspected source of the infection, for example:
A Chest X-ray may show signs of pneumonia or any other lung infection.
CT imaging may reveal abdominal abscesses, perforation of the bowels.
An ultrasound can rule out pelvic sources of infection, as well as in organs such as the gall bladder.
Cardiac tests (electrocardiogram and troponins) may reveal suspected causes such as Myocardial Infarction.
Routine tests such as Complete Blood Count and Chemistry studies provide a baseline analysis for infection screening and organ dysfunction (kidney and liver).
Procalcitonin is a sepsis biomarker and increases in the presence of systemic bacterial infection.
Blood, urine, and source cultures should be taken for organism identification and antibiotic sensitivities.
Certain clinical presentations may necessitate abscess aspiration, lumbar puncture, or paracentesis.
Arterial blood gas is also a beneficial test for analyzing how septic a patient may be.
It is also important to note that serum lactate has become an important test in diagnosing sepsis, especially in relation to septic shock. (Lee and An, 2016)
The image below provides a summary of test results related to sepsis, as adapted from Mahapatra and Heffner (2020):
Treatment of Sepsis
The foundational aspects of treating sepsis rest upon rapid recognitionand rapid remedy.
Schmidt and Mandel (2021) explain that resuscitation must be aggressively instituted in order to reperfuse the organs; just like antibiotic therapy, fluid resuscitation should be implemented within the first hour. It is given at 30 mL/kg and should be finalized by the third hour.
Initial antibiotic therapy should aim to cover both gram-positive and gram-negative organisms, any other considerations must be fully in line with the information found in the patient’s history, and physical examination. Where the source of infection necessitates surgical intervention, this must be pursued additionally.
The patient’s response to the treatments should be continuously monitored for improvements or worsening condition, and appropriate transfers should be pre-empted, for example, if the patient needs to be transferred to the Intensive Care Unit.
Key Points
Sepsis is a clinically heterogeneous syndrome, which has a progression that can lead to severe cellular, metabolic, and overall hemodynamic dysfunction.
If left un-recognized or, if it is not treated aggressively, the patient outcomes may be dim.
The SOFA score is a criteria that is used in-depth and in a quick overview to assess the level of organ dysfunction in suspected or confirmed sepsis.
Patients should be consistently monitored while exploring for the possible primary source.
Sepsis is treated with rapid infusion of intravenous fluids and by using broad-spectrum antibiotics.
Lee, S. M. and An, W. S. (2016) ‘New clinical criteria for septic shock: serum lactatee level as new emerging vital sign’ Journal of Thoracic Disease. 8(7)pp. 1388-1390 [Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958885/ (Accessed 23rdMay, 2021)
Singer, M. et al. (2016) ‘The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)’ JAMA.315(6)pp. 801-810[Online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4968574/ (Accessed 22ndMay, 2021)
This patient presents to the Emergency Department with altered mental status and fever. Altered mental status can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more. The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination. One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”. The table below outlines this mnemonic.
This patient has confusion, fever, lower abdominal pain, dysuria, and no focal neurological deficits on exam. Diabetic ketoacidosis (Choice A) is unlikely as the patient does not have marked hyperglycemia (>250mg/dL (13.8mmol/L)), polyuria, or polydipsia. Intracranial hemorrhage (Choice C) is unlikely as the patient has no headache, history of trauma, focal neurologic deficits, or coma. Severe hypothyroidism (Choice D), known as myxedema coma, can cause altered mental status. This condition is marked by somnolence or coma, hypothermia, nonpitting edema on the hands and feet, dry skin, macroglossia (enlarged tongue), and hair loss. This patient does not have symptoms consistent with severe hypothyroidism.
Sepsis (Choice B), especially in elderly individuals, can cause altered mental status. The patient’s fever, confusion, lower abdominal pain, and dysuria all point to a likely diagnosis of urosepsis. Sepsis is the most likely cause of this patient’s disoriented state. Treatment with early IV hydration and antibiotics will help remedy the patient’s altered mental status. Correct Answer: B
Arecoline toxicity is rarely seen in the Emergency Department [1]; however, doctors and emergency workers should be aware of this plant and the intoxication it causes. The alkaloids associated with this intoxication are reported in multiple regions of the world. It is important to emphasize how arecoline is the fourth most consumed psychoactive substance after nicotine, ethanol, and caffeine.
What is the “Betel nut”?
The tropical Betel palm (Areca catechu) produces the Betel nut (it is not a fruit but the seed of this plant). The Betel nut contains piperidine alkaloids which have substantial psychostimulating effects. Among these alkaloids, arecoline isprimarily responsible for the muscarinic, nicotinic, and psychostimulating effects of Betel nut consumption. Other alkaloids are arecaine, arecolidine, isoguvacin, and guvacine.
Coloured areca nuts [Areca catechu] in the market. Bago, Burma [Myanmar] It is this red color that determines the color of the spits of the people who consume the “paan” (from: LBM1948 – Wikipedia – CC BY-SA 4.0)
What is the “Betel leaf”?
It is the leaf of a tropical liana belonging to the Piperaceae family. It contains phenolic aromatic compounds, such as cavibetol and cavitol, and in some plants, also a third compound called caditene. Also, it, like the paper of a candy, contain chopped Betel nut mixed with lime (calcium hydroxide, which has a preservative action) and other substances typical of the community that produces it (e.g., tobacco, tamarind, or cardamom)
How is Betel nut consumed?
The Betel nut is thinly cut, combined with lime (to extract the alkaloids), and wrapped in a Piper beetle leaf, giving it its aroma and increasing salivation. It is consumed through chewing, which is usually not accompanied by swallowing, instead being spat out.
Photograph of an areca nut vendor on the island of Hainan, China. (from: Rolfmueller – Wikicommons – CC BY-SA 3.0)
Where is Betel nut chewed?
About 200 million people around the world consume Betel nuts. Primarily produced in Southeast Asia (Myanmar, Thailand, Laos, Cambodia, and Taiwan), it is consumed in Southern China (Yunnan, Xingtan, Hainan Island), Ceylon, Micronesia (Saipan, Guam, Palau, Mariana Islands), Papua, New Guinea, the Indian subcontinent (India, Pakistan, Bangladesh), and the Philippines.
New consumption territories are Melanesia, New Zealand, Australia, and immigrants living in Europe and North America [2].
Why is Betel nut consumed?
The consumption of Betel nut is voluptuous, and the reasons given by consumers are many. In general, it is consumed to “stay awake” and therefore “work harder” and the sensation of heat and energy during chewing. The reasons also include supposed medical and health reasons, such as “strengthening the teeth”, “helping digestion”, and “freshening the breath”. The cultural aspect of its consumption should not be underestimated in Buddhist culture and during some marriage ceremonies in Maharashtra. Betel leaf and Areca nut consumption are common. At the same time, in many countries, it is convivial to consume Betel at the end of the meal.
What is arecoline?
It is a potent agonist of muscarinic and nicotinic receptors [3]. In addition, the calcium hydroxide in the product causes the arecoline to be hydrolyzed into arecaidine, which is a potent inhibitor of Gaba uptake. The result is a strong excitation of the nervous system due to the release of catecholamines (adrenaline and noradrenaline). Pregnant women who chewBetel nuts can transfer the active ingredients via the placenta to the fetus [4].
What are the symptoms of acute Arecoline intoxication?
It is a rare event [5].
The psychological acute arecoline intoxication symptoms are:
increased heart rate/palpitations
increased systemic pressure
increased temperature
increased sweating
increased salivation
nausea, vomiting
In some cases, it can lead to coma, respiratory failure, myocardial infarction.Therefore it is recommended that the patient be monitored closely and treated for cholinergic, neurological, cardiovascular, and gastrointestinal manifestations.
From the EEG point of view, we have widespread cortical desynchronization. So, in case of high consumption, psychosis can arise [7].
Woman with red gingivas chewing paan in Don Det in Laos. Paan is a preparation combining betel leaf with areca nut and tobacco. It is chewed for its stimulant and psychoactive effects. (from: Basile Morin, Wikipedia, CC BY-SA 4.0)
What symptoms does chronic arecoline intoxication give?
Chewing Betel nut leads to discoloration of normal dental enamel, similar to that observed in those who chew tobacco (often Tabac and Betel nut are chewed together). The saliva in the chewing of this nut becomes red and with a markedly alkaline pH. The mucous membranes, gums, and teeth take on this color. Consumption is associated with the development of necrotizing ulcerative gingivitis (ANUG), which is a bacterial infection of the periodontal tissue that can also cause systemic symptoms, such as lymphadenopathy and malaise.
What are the risks of chronic exposure to arecoline?
Betel consumers have an increased risk of cancer of the oropharynx, liver, and uterus [8] . Chronic consumption leads to evident stains on the dental enamel (black tartar) and marked red salivation for the release of tannins. Also, its consumption is predisposing for the development of oropharyngeal carcinoma as nitrogenous compounds deriving from the alkaloids are released. About 60% of oro-pharyngeal cancers occur in areas where people chewed Betel nut.
This patient presents to the Emergency Department with altered mental status. This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more. The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination. One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”. The table below outlines this mnemonic.
This patient has a markedly elevated glucose level. All patients with altered mental status should have a point of care glucose test as both hypoglycemia and severe hyperglycemia can cause altered mental status. Some diagnoses to consider in this patient are diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Both of these diagnoses can present with hyperglycemia and altered mental status, but HHS more often presents with higher glucose levels (greater than 600mg/dL (33mmol/L)) and more pronounced Central Nervous System depression. Patients with HHS may have severe somnolence to the point of coma and may require intubation for airway protection. In both DKA and HHS, patients are severely dehydrated by osmotic diuresis. High glucose levels in the serum create an osmotic gradient that causes increased urination and fluid loss. The first step in treatment for DKA and HHS is volume resuscitation.
IV fluids (Choice C) should be given prior to the initiation of insulin therapy (Choices A and D). After adequate IV hydration and correction of electrolyte derangements, insulin can be started to normalize glucose levels. Bolus doses of IV insulin (Choice D) are harmful in both DKA and HHS and increase the risk of cerebral edema development. For this reason, an IV insulin continuous infusion (Choice A) is always preferred over an insulin bolus (Choice D). IV hypertonic 3% NaCl (Choice B) is the treatment for severe hyponatremia causing altered mental status or seizure. Severe hyperglycemia can cause pseudohyponatremia, but this can be corrected for using the standard sodium correction formula (see references below). The question stem provides an explanation for this patient’s altered mental status (hyperglycemia), so hypertonic saline should not be given with the information provided. IV fluid administration (Choice C) is the next best step. Correct Answer: C
Examples of system failure are littered around the medical field and often disguised as professionalism or better yet heroism. “One resource seems infinite and free: the professionalism of caregivers”, says an opinion piece published in The New York Times. The article goes on to say that an overwhelming majority of health care professionals do the right thing for their patients, even at a high personal cost. Noteworthy is the availability heuristic that comes into play. “Of course they should work in favor of their patients, no matter what, isn’t that why they chose the medical profession!?”, you ask. They sure did. A lot of why you believe that medical professionals must go out of their way to help patients can be explained by what news you are being exposed to these days. The availability heuristic! That kept aside the gist of the article can roughly be summed up in the following excerpt
“Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just a bad strategy. It’s bad medicine. This status quo is not sustainable — not for medical professionals and not for our patients.”
I invite you to, for some minutes, drop all the preoccupation and think about it logically. I have, time and again, submitted myself to the idea that empathy and not logic is the best way to get my point across. But today, let us first think about some pertinent analogies.
As we anticipate the dreaded tsunami of COVID-19, many governmental healthcare institutes are sending out a notice for recruiting doctors and nurses for a certain time. My sister who is a nurse said, “Why do they have to make it sound like we are disposable?”. To which, I wittingly replied, “ Well they are probably looking for paid volunteers.” But the same recurring theme covers the core of our conversation. We simply were treating healthcare as a per-need industry. When the reality is, again, a contrasting opposite. Indeed, healthcare is a backup industry. You do not wish to use it when things are going smoothly. The healthcare system of any country should stand on its mighty ability to deal with crises.
Most other industries can either do with the number of people already in the industry or have to let go of people they already had, during a disaster. That is a contrasting opposite to the healthcare industry. Every time the health of the public is threatened we start to search for volunteers and temporary hires. I argue this is because the healthcare industry is ruled by businesses in the most powerful countries. To the point that the notion of just enough or even fewer doctors working in a setting is looked upon as a heroic measure. I don’t suppose you would say. “Oh! That busy bank has only one teller, and she also works as a receptionist. How heroic of her!”, do you?
There are reserves in almost every industry. Take transportation as another example: I visited Kathmandu on a night bus during my vacation as a child. My dad introduced me to two men. Both of them were drivers. I was taken by surprise when I found out the bus only had one steering wheel. “What would the other driver do!?”, the inquisitive child in me asked. My dad was semi-asleep when he answered, “They will drive for the whole night. Don’t you think they need to rest?”. I sure do Dad, I sure do!
In aviation, the first officer (FO) is the second pilot (also referred to as the co-pilot) of an aircraft. The first officer is second-in-command of the aircraft to the captain, who is the legal commander. In the event of incapacitation of the captain, the first officer will assume command of the aircraft. A second officer is usually the third in the line of command for a flight crew on a civil aircraft. Usually, a second officer is used on international or long haul flights where more than two crews are required to allow for adequate crew rest periods.
There have been some examples of what would be analogous to a natural disaster in other industries. Let us take some economic ups and downs as examples. Remember, India demonetized Rs. 500 and Rs. 1000 notes? Bankers had to work extra hours to make sure the undertaking completed in due time. They, of course, were paid an extra allowance for that. Interestingly they did not have to open up more positions for the work to be carried out. Remember the great economic recession? It “forced” business owners to let go of their employees. Not recruit more!
I vividly remember feeling proud of one of my seniors who was portrayed as an ideal healthcare worker. “He was arranging the medicine cabinet when we visited him”, one of my professors boasted. I felt not only proud but a desire to be at his place and do as he did one day. Today I understand that 1) he could be doing something way more productive and 2) what my senior was doing when my professor reached there was a clear example of a system failure.
Let me give you an example of my intern year to demonstrate the lack of consideration of the human element in designing healthcare systems. I had to take leave for some days. It was the flu. I understand that the coronavirus situation has alchemized the glory that flu deserved all along, but those were different times. I had a severe sore throat and my body ached like some virus was gnawing on my bones. I remember feeling very guilty about being ill because while I was sniffing Vicks and popping paracetamols in the hostel. My friends (fellow interns) were working their asses off. But when the system was designed, did no one think that someone might get sick? I mean, we work around infections every day. C’mon system designers, that is blindness, not just shortsightedness. The irony is: we are in an industry where we boast about our ability to empathize with human pain, suffering, and ill-health.
Human development has been punctuated by disasters of some sort, time and again. It is almost comical that we haven’t learned our lessons and that harrowing circumstances have to keep reminding us of the need for preparedness. It almost feels like I am writing a reminder the second time. After I failed to follow through my previous reminder. For me, the first time was the Nepal earthquake 2015. I am sure you have your own first time. I can only speak of the healthcare industry because that is what I have been fortunate enough to see closely. I am sure preparedness means different things in different settings. For healthcare, it means 1) taking into account the human element and 2) realizing that healthcare is a backup industry.
Occam’s Razor – the simplest explanation is most likely to be correct.
In the Emergency Room, we are faced with a multitude of cases, and Occam’s Razor serves best when we need to narrow down on the differential diagnoses.
Sometimes, a few cases may evade this category and continue to baffle us even after a thorough history is obtained or a detailed clinical examination is performed. If we are lucky enough to get the point-of-care (POC) lab tests in time (or the mere availability of POC), they aid in the diagnosis and decision-making. At times, these POC lab tests also may not provide much help.
I have described one such case – a 21-year-old male with fever, dyspnea, desaturation, and multiple petechiae of 3 days duration.
Case Presentation
A 21-year-old male came at 9.30 pm to the ER with fever and breathlessness for three days. Being a healthcare worker himself, he had suspected pneumonia and started oral Amoxiclav, oral Clarithromycin, and Paracetamol. Despite this, there was no improvement in clinical status. He had progressively worsening breathlessness and continuous low-grade fever. On day 3, he developed a few petechial spots over his arms and minimal subconjunctival hemorrhage.
He recalls having myalgia in the lead up to these symptoms, for which he had received several injections of intramuscular Diclofenac. The injection sites now had developed small hematomas. There were no other visible bleeding manifestations. He clearly said that he had had no contact with any infectious patients and had self-isolated after developing these symptoms. His workplace had sent blood and sputum cultures – which came back negative. Their only concern was a continuous rise in the WBC count and sent to our hospital for further management.
Assessment
The patient was very ill-looking and extremely dyspneic with obvious usage of accessory respiratory muscles. He was profusely diaphoretic, had bilateral subconjunctival hemorrhage, multiple petechiae, anasarca, dyspnea, and 99.6⁰F. His Vitals were heart rate – 134/min, blood pressure – 110/70mmHg, respiratory rate – 34/min, SpO2 – 72% in room air; 98% with NIV. There were bilateral crepitations in all lung fields + no obvious abnormalities on CVS, CNS, and abdominal examination. POC ultrasound revealed multiple B-lines in all lung areas. Dilated IVC. The remaining cardiac, abdomen, and limb USGs were normal. ABG revealed Type 1 respiratory failure with elevated lactates. Bedside CXR and chest CT revealed diffuse bilateral lung infiltrates – not typical of pulmonary edema or pneumonia. Probable ARDS was mentioned. Blood samples had been sent for necessary investigations, including cultures and peripheral blood smear.
Management
Meanwhile, opinions were obtained from critical care consultants and pulmonologists regarding further management. Based on the clinical findings, it was decided to start the patient on broad-spectrum antibiotics (BSA), albumin transfusion, diuretics for the fluid overload status, and NIV for respiratory failure [all in suspicion of sepsis with MODS]. The patient was started on BSA before shifting to the ICU. Meanwhile, the blood reports arrived, suggestive of possible Myelodysplastic Syndrome (WBC – 95,000 cu.mm), Hb – 7g/dl. Peripheral Blood Smear report was Acute Myeloid Leukemia – possible M2 or M3.
The patient was immediately started on IV fluids, and oncology consultation was immediately obtained for chemotherapy initiation. Albumin and diuretics were withheld in suspicion of blast crisis and leukostasis / leukemic infiltration of the lungs. The patient was started on Cisplatin and other chemotherapeutic agents; bicarbonate infusion for urine alkalinization; allopurinol to treat hyperuricemia due to cytolysis; aggressive IV fluids for prevention of AKI due to chemotherapy and hyperuricemia [Tumour Lysis Syndrome]. Bone marrow biopsy was done during his hospital stay, which confirmed blast crisis AML-M3. His clinical condition improved considerably, and he was discharged from the hospital on Day 7.
While considering different diagnoses based on clinical findings, always keep an open eye. Rare diseases present to the ED just like all others. https://www.medscape.com/viewarticle/860747_3
Aggressive fluid management is needed in hyperviscosity syndrome. If we had started this patient on diuretics as planned, the blood would have become more viscous and lead to multisystem thrombosis. https://pubmed.ncbi.nlm.nih.gov/22915493/
Increased metabolism in AML can present as pyrexia. With the other features of anemia, leucocytosis, petechiae, and anasarca, we are likely to diagnose this as sepsis. When in doubt, look through other causes of pyrexia (PUO). https://onlinelibrary.wiley.com/doi/full/10.1111/imj.13180
In 2000, the ST-Elevation Myocardial Infarction (STEMI) paradigm revolutionized the management of Acute Coronary Syndrome (ACS), substituting the previous dichotomy between Q-wave versus non-Q wave myocardial infarcts (MI). Subcategorizing aimed to predict completely occluded arteries and the need for immediate intervention, namely, emergent cardiac catheterization to open an occluded coronary artery in STEMI. However, literature has shown that STEMI and occlusion myocardial infarction (OMI) are not interchangeable, with clear evidence of benefit from early reperfusion in both entities. Moreover, definitions STEMI and Non-ST-elevation myocardial (NSTEMI) can miss a large proportion of acute coronary occlusions; STEMI as a category can miss 30% of occlusion MI up to 50% in left circumflex, and NSTEMI was only associated with total MI in a quarter of cases.
As any Emergentologist at any level can relate, it was only recently when my ED held a morbidity and mortality meeting for a presumably delayed cath lab activation. The patient had all the risk factors, a typical chest pain which resolved in the ED, normal vitals and an ECG that didn’t meet the STEMI criteria; however, when he went for urgent angiography, the LAD was totally occluded.
A new paradigm: OMI vs. NOMI
The OMI manifesto, introduced by Dr Stephen Smith, Dr Pendell Myers, and Dr Scott Weingart might provide a better solution in the management of ACS. The fundamental question is: Does the patient have an acute coronary occlusion that would benefit from immediate intervention? Based on this question, the following diagram was suggested to substitute STEMI versus NSTEMI paradigm. The manifesto also contains rules to diagnose acute MI in certain categories of patients, such as patients with left bundle branch block (LBBB), left ventricular paced rhythm, terminal QRS distortion, normal ST-elevation vs. left anterior descending artery (LAD) occlusion, anterior ventricular aneurysm vs. acute MI, ST depression in aVL.
ACS is a spectrum of clinical presentations divided into STEMI, NSTEMI and unstable angina, based on ECG findings and cardiac markers. The American Heart Association/American College of Cardiology (AHA/ACC) and European Society of Cardiology (ESC) define STEMI as new ST elevation at the J point in the absence of LV hypertrophy or LBBB in at least 2 contiguous leads. The elevation must be at least 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or 1 mm (0.1 mV) in other contiguous chest leads or the limb leads.
AHA/ACC recommends primary percutaneous coronary intervention (PCI) for patients with STEMI and ischemic symptoms of less than 12 hours’ duration. In NSTEMI, the recommendation is to perform urgent/immediate angiography with revascularization if appropriate in patients who have refractory angina or hemodynamic or electrical instability.
A meta-analysis of 46 trials with a total of 37 757 patients, including data from the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) and Complete versus Culprit-Only Revascularization Strategies to Treat Multi-vessel Disease after Early PCI for STEMI (COMPLETE) trials demonstrated that PCI prevents death, cardiac death, and MI in patients with unstable coronary artery disease (CAD). The study defined unstable CAD as post-MI patients who haven’t received reperfusion therapy, multi-vessel disease following STEMI, non–ST-segment–elevation acute coronary syndrome.
STEMI Equivalents
For patients with persistent chest pain, hemodynamic instability and certain patterns of EKGs, it’s advisable to consider immediate/urgent PCI. The following patterns were found consistent with total occlusion or critical ischemia of the coronaries so every Emergentologist should familiarize her/himself with those: (All displayed ECGs are from Life in the Fast Lane ECG library)
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., … & Zieman, S. J. (2014). 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes. Journal of the American College of Cardiology, 64(24), e139-e228.
Chacko, L., P. Howard, J., Rajkumar, C., Nowbar, A. N., Kane, C., Mahdi, D., … & Ahmad, Y. (2020). Effects of percutaneous coronary intervention on death and myocardial infarction stratified by stable and unstable coronary artery disease: a meta-analysis of randomized controlled trials. Circulation: Cardiovascular Quality and Outcomes, 13(2), e006363.
Khan, A. R., Golwala, H., Tripathi, A., Bin Abdulhak, A. A., Bavishi, C., Riaz, H., … & Bhatt, D. L. (2017). Impact of total occlusion of culprit artery in acute non-ST elevation myocardial infarction: a systematic review and meta-analysis. European heart journal, 38(41), 3082-3089.
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This patient presents to the Emergency Department with altered mental status. This presenting symptom can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more. The management and evaluation of a patient with altered mental status depend on the primary assessment of the patient (“ABCs,” or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination. One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS.” The infographic below outlines this mnemonic.
This patient is awake and moving all extremities, but with obvious confusion and dysarthria. Ordering a CT scan of the head without contrast (Choice A) may be helpful in this patient to evaluate for intracerebral hemorrhage, stroke, or a brain mass. However, the question stem indicates that this patient has a low glucose level. Glucose is considered low at levels below 70mg/dL (3.9 mmol/L); however, the absence of any symptoms can be reassuring. Glucose levels that are more severely low (less than 40mg/dL (2.2 mmol/L)) are more concerning than levels that are only moderately low (less than 70mg/dL (3.9mmol/L)). All patients with altered mental status should have a point of care glucose test. Both hypoglycemia and severe hyperglycemia can cause altered mental status. Hypoglycemia, if left untreated, can cause permanent brain damage. For this reason, the prompt identification of low blood glucose is critical so it can be treated rapidly.
Administration of IV hypertonic 3% NaCl (Choice B) would be helpful in a patient with severe hyponatremia with altered mental status or seizure. However, the question stem provides a cause for the patient’s symptoms (low glucose). IV potassium chloride (Choice D) would be helpful in the case of hyperkalemia to stabilize the cardiac membrane. Severe hyperkalemia can cause weakness and arrythmias, but does not cause dysarthria. This patient is at higher risk for hyperkalemia as he is a hemodialysis patient, but no evidence is given that he has hyperkalemia (i.e., peaked T waves on EKG or widened QRS interval). Again, a low glucose level is given in the question stem, which should be treated first.
IV dextrose (Choice C) is the best next step in management for this patient’s hypoglycemia. This patient has had poor oral intake and has end-stage renal disease. Insulin is excreted by the kidneys, so patients with end-stage renal disease are more prone to insulin “buildup” and hypoglycemia. In addition to administering IV dextrose (i.e., D50 bolus), providing food with complex carbohydrates is important to prevent recurring hypoglycemic episodes. If the patient continues to have persistent hypoglycemia despite an IV dextrose bolus and food, a continuous IV dextrose infusion (i.e., D10W at 100cc/hour) and admission for further evaluation should be considered. Correct Answer: C
In some parts of the world, Internships consist of rotating in different departments of a hospital over a period of one or two years depending on the location. In others, interns are first-year Emergency Medicine residents. Whichever country you practice in, an emergency rotation may be mandatory to get the most exposure, and often the most hands-on.
Often, junior doctors (including myself) find ourselves confused and lost as to what is expected of us, and how we can learn and work efficiently in a fast-paced environment such as the ER. It can be overwhelming as you may be expected to know and do a lot of things such as taking a short yet precise history, doing a quick but essential physical exam and performing practical procedures.
I’ve gathered some tips from fellow interns and myself, from what we experienced, what we did right, what we could’ve done better and what we wish we knew before starting.
These tips may have some points specific to your Emergency Medicine Rotation, but overall can be applied in any department you work in.
First things first – Always try to be on time. Try to reach your work a couple of minutes before your shift starts, so you have enough time to wear your PPE and feel comfortable before starting your shift.
Know your patients! Unlike other departments, ER does not always have rounds, and you do not know any of the patients beforehand, but it always helps to get a handover from the previous shift, and know if any of the patients have any results, treatment plans or discharges pending, to prevent chaos later on!
Always be around, inform your supervising doctor when you want to go for a break, and always volunteer to do more than what you’re asked for. The best way to learn is to make yourself known, ask the nurses to allow you to practice IV Cannulation, Intramuscular injections, anything and everything that goes around the department, remember the ER is the best place to learn.
Admit when you feel uncomfortable doing something, or if you’ve done a mistake. This makes you appear trustworthy and everyone respects someone who can own up to their mistake and keeps their patients first.
Breath sounds and pulses need to be checked in every patient!
Address pain before anything else, if their pain is in control, the patient will be able to answer your questions better.
Never think any work is below you, and this is one thing which I admired about ED physicians, you do not need someone to bring the Ultrasound machine to you, you do not need someone to plug in the machine, you do not need someone to place the blood pressure cuff if you can do it yourself. Time is essential, and if you’re the first person seeing the patient, do all that you can to make their care as efficient as possible.
Care for patients because you want to, and not for show. Often junior doctors get caught up in the fact that they are being evaluated and try to “look” like the best version of themselves. While it may be true, remember this is the year where you are shaping yourself for the future, and starting off by placing your patients first, doing things for their benefit will not only make it a habit, the right people will always notice and will know when you do things to provide patient-focused care, or when you do them to show that you are providing patient-focused care.
Teamwork will help you grow. Not everything in life has to be a competition, try to work with your colleagues, share knowledge, take chances on doing things, learn together, trying to win against everyone else only makes an easier task even more stressful and can endanger lives.
Learn the names of the people you work with! In the ER, you may across different people on each and every shift and it may be difficult to remember everyone’s names, but it’s always nice to try, and addressing people by their names instantly makes you more likable and pleasant to work with!
Keep track of your patients and make a logbook of all the cases you see and all the procedures you observe/assist in/perform. This not only helps in building your portfolio, but also in going back and reading about the vast variety of cases you must have seen.
Always ask yourself what could the differential diagnosis be? How would you treat the patient?
Ask questions! No question is worth not asking, clear your doubts. Remember to not ask too much just for the sake of looking interested, but never shy away from asking, you’d be surprised to see how many doctors would be willing to answer your queries.
Don’t make up facts and information. If you forgot to ask something in history, admit the mistake, and it’s never too late, you can almost always go back and ask. It’s quite normal to forget when you’re trying to gather a lot of information in a short span of time.
Check up on the patients from time to time. The first consultation till the time you hand them the discharge papers or refer them to a specialty shouldn’t be the only time you see the patient. Go in between whenever you get a chance, ask them if they feel better, if they need something. Sometimes just by having someone asking their health and mental wellbeing is just what they need.
Take breaks, drink water and know your limits. Do not overwork yourself. Stretching yourself till you break is not a sign of strength.
Sleep! Sleep well before every shift. Your sleep cycles will be affected, but sleeping when you can is the best advice you can get.
Practice as many practical skills as you can. The ER teaches you more than a book can, and instead of looking at pictures, you can actually learn on the job. Practice ultrasound techniques, suturing, ECG interpretation, see as many radiology images as you can, learn to distinguish between what’s normal and what’s not.
Last but most important, Enjoy! The ER rotation is usually amongst the best rotations an intern goes through, one where you actually feel like you are a doctor and have an impact on someone’s life! So make the best of it.
In the ED, we often see patients presenting amid an emotional crisis – whether it’s a panic attack, or a period of extreme anxiety or stress, or a feeling of being overwhelmed. In fact, it is not just patients. We as humans can experience this too, finding ourselves in situations where we feel overwhelmed, unable to deal with our emotions, and not knowing what to do next. For this reason, I wanted to provide some tips on coping with an emotional crisis, that I learned during my psychiatry rotation. In psychiatry, we called these “distress tolerance skills”, which is a component of Dialectical Behavioural Therapy.
One distress tolerance skill is TIPP – which stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation.
Temperature: During a crisis, our body may feel hot. So, it can be helpful to come into contact with something COLD. This can include eating/drinking something cold, tapping a cool cloth on yourself, splashing cold water on your skin, standing out in the cold or front of an air conditioner, or holding an ice cube. Whatever is convenient! This will “cool” you down both literally and emotionally.
Intense Exercise: At times, feelings become overwhelming, and you may become full of anxious energy. Performing intense exercise on a daily basis can act as an outlet to release negative emotions and energy and can decrease stress levels. This can be any form of intense exercise, including jogging on the spot, doing jumping jacks, going on a run, or going to the gym.
Paced Breathing: This is a technique of taking slow, deep breaths. It can heighten performance and concentration while also being a powerful stress reliever with a soothing effect. One way of doing this is box breathing, which actually has evidence for regulating the autonomic nervous system. Here are the steps for box breathing:
Close your eyes. Inhale through your nose while slowly counting to four.
Now, hold your breath inside while counting slowly to four again. Try not to clamp your mouth or nose shut.
Begin to slowly exhale for 4 seconds.
Now, hold your breath there while counting slowly to four again.
Repeat these steps multiple times daily, for 5 minutes at a time.
Progressive Muscle Relaxation: This is a technique that helps to slow down your heart rate and breathing, while also releasing the muscle tension that often accompanies anxious feelings. To perform this, you first tense particular muscle groups in your body, such as clenching your fist, while you slowly inhale. Next, you release this tension, e.g. slowly unclench your fist, while you slowly exhale.
Focus on what helps you, and encourage patients to focus on what helps them. This may involve identifying problematic ways of coping with anxiety that end up exacerbating anxiety in the long term, such as resorting to alcohol. Other daily things that may be helpful include meditation, yoga, exercise, and getting adequate sleep. Maintaining a routine can be beneficial. Any relaxation exercise of your preference, that helps you be more present in the moment and slow down your thoughts, will help in times of an emotional crisis. Many people find it helpful to keep a journal on a daily basis to collect their thoughts, and to keep up hobbies they enjoy such as sports, hiking, walking, spending time with loved ones, cooking, and so on. I hope you found this blog post helpful, not just for ways to help patients going through an emotional crisis, but yourself too. Feel free to leave a comment below with additional strategies you have found helpful to cope with an emotional crisis!
